new developments for case conceptualization in emotion-focused

New Developments for Case Conceptualization inEmotion-Focused Therapy

Ladislav Timulak1* and Antonio Pascual-Leone21 School of Psychology, Trinity College Dublin, Dublin 2, Ireland2Department of Psychology, University of Windsor, Windsor, Ontario, Canada

Emotion-focused therapy (EFT) has increasingly made use of case conceptualization. The current paperpresents a development in the case conceptualization approach of EFT. It takes inspiration from recentresearch on emotion transformation in EFT. The case conceptualization presented here can guide thetherapist in listening to the client’s narrative and in observing the client’s emotional presentation insessions. Through observing regularities, the therapist can tentatively determine core emotion schemes’organizations, triggers that bring about the emotional pain, the client’s self-treatment that contributes tothe pain, the fear of emotional pain that drives avoidance and emotional interruption strategies. The frame-work recognizes global distress, into which the client falls, as a result of his or her inability to process theunderlying pain, the underlying core pain and the unmet needs embedded in it. This conceptual frameworkthen informs therapists as to which self-organizations (compassion and protective anger based) have to befacilitated to respond to the pain and unmet needs, so that they might transform it. The conceptualframework can guide the therapist’s thinking/perceptions and actions in the session. Copyright ©2014 John Wiley & Sons, Ltd.

Key Practitioner Message:• Therapists can better facilitate emotional transformation when they understand the dynamics involved

in the client’s distress.• Emotion transformation is facilitated by first helping the client to access the core underlying painful

feelings and unmet needs embedded in them and then by helping the client to generate adaptiveemotional responses to those unmet needs.

Keywords: Emotion-Focused Therapy, Case Conceptualization, Emotion Transformation, EmotionalProcessing

INTRODUCTION

Case conceptualization is a defining feature of psychother-apy. Each therapist attempts to understand his or herclient’s presenting issues, so he or she might apply a ther-apeutic strategy in order to address them. Traditionally,humanistic and experiential approaches to therapy havedownplayed this therapist activity, as they rather preferredand valued the authenticity of the relational encounter intherapy (e.g., Rogers, 1951). Thus, traditional methodsfocused on the immediacy of the therapeutic encounterand the client’s ever-changing experiencing as a form ofcase conceptualization. Current experiential approachessuch as emotion-focused therapy (EFT), a research-informedapproach that focuses on transformation of problematicemotions by generation of healthy ones (Greenberg, 2011),continued in this tradition. Therapeutic work in EFT tradi-tionally focused on the provision of a validating empathic

relationship and the empathic exploration of a client’s emo-tional experience. This effort in the relationship was furthersupplemented by a focus on the processing of unresolvedemotional problems as they emerged moment by momentduring the client’s in-session process. To this end, EFT thera-pists focused on a process (marker-guided) diagnosis inwhich a specific client presentation in the therapy session(e.g., unfinished business with significant other) led therapistto apply a particular task (an empty-chair dialogue) thattypically followed a research-informed model of work(Greenberg, Rice, & Elliott, 1993).The EFT approach has also been based on an ongoing

emotion assessment (Greenberg et al., 1993) that traditionallydistinguishes between primary emotions (very firstemotional reactions to triggers), secondary emotions (reac-tions to primary emotions or accompanying thoughts) andinstrumental emotions (acted emotions fulfilling someneed). EFT also distinguishes between adaptive and mal-adaptive emotions depending on how they are experiencedand what actions they inform (cf. Greenberg, 2011). EFTtherapists focus on the primary emotions: when primarymaladaptive emotions are accessed, therapists seek to help

*Correspondence to: Ladislav Timulak, School of Psychology, TrinityCollege Dublin, Dublin 2, Ireland.E-mail: [email protected]

Clinical Psychology and PsychotherapyClin. Psychol. Psychother. (2014)Published online in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/cpp.1922

Copyright © 2014 John Wiley & Sons, Ltd.

clients transform them by way of more primary adaptiveemotions (Greenberg, 2011).However, although the relationship, empathic explora-

tion and emotion assessment as well as the use of experien-tial tasks remain central, EFT increasingly views caseconceptualization as important for treatment (Greenberg& Goldman, 2007; Greenberg & Watson, 2006; Watson,2010). This conceptualization emerges co-constructivelybetween the therapist and the client during the process oftherapy and is an important part of the empathic exploration(Greenberg & Goldman, 2007). As described in the literatureso far, it contains eight steps that are followed fluidly and areattended to across therapy sessions (from Greenberg &Goldman, 2007; Greenberg & Watson, 2006). These are asfollows: (1) identification of the presenting problem; (2) ex-ploration of the client′s narrative about the presenting prob-lem; (3) gathering of information about past and currentidentity and attachment-related experiences; (4) identifica-tion of the ‘core pain’ (i.e., the most painful and poignantexperiences); (5) observation and attention to the client’sstyle of processing emotions (i.e., whether the client isover-regulating or under-regulating his or her emotions);(6) identification of thematic interpersonal and intraper-sonal processes; (7) identification of markers informingthe choice of therapeutic tasks (EFT uses a variety of expe-riential techniques that are used at particular ‘markers’—the clients’ in-session presentations—Elliott, Watson,Goldman, & Greenberg, 2004; Greenberg et al., 1993);and finally, (8) attention is paid to moment-to-momentprocess within the session and tasks.The existing EFT case conceptualization (Greenberg &

Watson, 2006; Greenberg & Goldman, 2007) representsan elaborated experiential approach to case conceptualiza-tion that isfirmly embedded in the empathic andvalidatingrelationship. However, the existing model is primarilydescriptive of what happens in therapy and apart fromguiding the therapist’s action in tasks (such as unfinishedbusiness dialogues), the model is not particularly informa-tive for an overall treatment strategy (e.g., in promotingthe client’s self-compassion). The current theoretical paperpresents an original development in emotion-focused caseconceptualization. Our contribution to EFT case conceptu-alization is built on recent research on sequential steps ofemotion transformation in EFT. As we also will argue, theapproach we present herein can be somewhat more directin informing a therapist’s overall treatment strategy, al-though still embedded in an empathic approach respectingthe client’s pace andmoment-to-moment experiencing. Theapproach we present here is somewhat more direct as itguides the therapist to go beyond moment-to-momentmarker focused responding. This approachhelps therapistsfocus on the distinct underlying painful emotions and un-met needs that their clients have and facilitation of specifichealing adaptive emotions. Thus, our approach provides adetailed description of emotional processing phases (cf.,

for instance, Greenberg & Watson, 2006). Before we startwith the presentation of the case conceptualization model,we briefly look at the empirically basedmodel of emotionaltransformation that was the starting point of our thinkingabout case conceptualization.

EMOTION TRANSFORMATION INEMOTION-FOCUSED THERAPY

Pascual-Leone and Greenberg (2007; Pascual-Leone, 2009)presented a model of productive emotional processing ofpainful emotions in experiential therapy for depressionand long-standing interpersonal difficulties (Figure 1).They showed that in good ‘in-session’ outcome events thatstarted with an experience of a high emotional arousaland undifferentiated pain, the emotional processingfollowed a particular path. This path consisted of severalstages: global distress stage (characterized by undifferenti-ated emotional pain, hopelessness, helplessness, confu-sion, despair etc.) was followed by a second stage offear/shame (characterized by enduring pain and experi-ences of inadequacy, fear, guilt etc.). Fear/shame stagewas further followed by a third stage characterized bynegative self-evaluation (e.g., self-critic, i.e., ‘I am inade-quate’) and the expression of need (e.g., ‘I need to beloved’). This was then followed by a fourth stage thatentailed the expression of assertive anger (‘I deserve to beappreciated’) and/or self-soothing (self-compassion) (‘I feelappreciated’) and grief/hurt (‘It was painful not to get theappreciation’—an experience that was without blame orresignation) and finally a sense of acceptance and agencyensued. Pascual-Leone and Greenberg also showed analternate pattern (see left side of Figure 1) in whichglobal distress was followed by second stage of rejectinganger (i.e., rage, hate, frustration and angry tears, directedtowards a hurtful other or noxious circumstances—characteristic by low differentiation of meaning). Someclients then directly proceeded to the later stage ofassertive anger and eventually grieving.Pascual-Leone (2009) further showed that clients in

good in-session outcome events progress alongside theoutlined stages in a sawtooth pattern (wedge-shapevariance with a rising-slope), in a two-steps-forward-one-step-back manner. This means that clients in goodin-session outcome events experienced a wider rangeof emotional states, with increasingly higher orderstages. However, advancements (i.e., moving downFigure 1) were often interrupted by regressions (i.e.,emotional collapses) back to the preceding stages ofshallower levels of processing. Pascual-Leone concludedthat clients in successful events increase their emotionalrange, emotional flexibility, with more adaptive and healthyemotional processing appearing with greater ease.

L. Timulak and A. Pacual-Leone

Copyright © 2014 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. (2014)

Work by Pascual-Leone (2005, 2009; Pascual-Leone &Greenberg, 2007) and collaborators (e.g., Kramer,Pascual-Leone, Despland, & de Roten, 2013; Paivio &Pascual-Leone, 2010) led the [Ladislav Timulak] (led by firstauthor) to a series of case studies that used the model devel-oped by Pascual-Leone and Greenberg (2007) as a basis forobserving emotional processing across all sessions of psycho-therapy in particular cases (primarily of clients with depres-sion, anxiety disorders and co-morbid personality disordersand clients with chronic illness) and further complementedobservations described in Pascual-Leone’s studies (e.g.,Crowley, Timulak, & McElvaney, 2013; Keogh, Timulak,& McElvaney, 2013; Keogh, O’Brien, Timulak, &McElvaney, 2011; McNally, Timulak, & Greenberg,2014; O’Brien, Timulak, McElvaney, & Greenberg, 2012;Timulak, Dillon, McNally, & Greenberg, 2012).Across those studies, we noticed that the emotion

transformation model’s framework helped us under-stand clients and their progress. We then started touse this understanding in our thinking about theclients, strategies for therapy and in teaching EFT.Thus, a case conceptualization model was developed,which we present in the following pages. We presentthe model within an EFT conceptualization of therapy,but in the paper ’s conclusions, we also discuss it inthe context of cognitive–behavioural and psychody-namic conceptualizations.

EMOTION-FOCUSED CASECONCEPTUALIZATION

Our thinking about the case conceptualization evolved intoa conceptual framework. Through observing re-occurringpatterns, the therapist (supervisor, researcher) can tenta-tively determine core emotional organizations. In EFT, theseorganizations are called emotion schemes, i.e., ‘emotionmemory structures that synthesize affective, motivational,cognitive, and behavioral elements into internal organizationsthat are activated rapidly, out of awareness, by relevant cues’(Greenberg, 2011, p. 38).Although the original model in Figure 1 already lends it-

self to case formulation, it remains for the model to befunctionally elaborated for the purpose of case formula-tion, using the cues, behaviours and processing difficultiesthat are most salient to emotion-focused therapists and su-pervisors. Thus, the developments presented in Figure 2offer a conceptual framework that has several layers,which interact together. The case conceptualization frame-work assumes that the client’s general distress, whichshows in the form of undifferentiated painful emotionscharacterized by hopelessness and helplessness (globaldistress) or by irritability (rejecting anger), is the responseto current and past triggers. These triggers represent situ-ations, in which the client’s needs were violated or notresponded to, which left the client with core painful

Figure 1. A sequential model of emotional processing (modified from Pascual-Leone & Greenberg [2007] and Pascual-Leone [2005])

Case Conceptualization in Emotion-Focused Therapy


Figure 2. The model of emotion transformation in therapy (applied to the case of Ann)



emotions (studies on primarily depressed and anxious cli-ents suggest that they are shame-based,loneliness/sadness-based and/or terror/fear-based—thisis somewhat akin to the psychodynamic formulation de-veloped by Blatt [2008] that distinguishes self-definitionalfrom relatedness aspects of personality and psychopathol-ogy). Since these core painful emotions are difficult to bearand there is a sense that the needs contained in them can-not be fulfilled, the client collapses to a more generalhopelessness and helplessness.Furthermore, the client is afraid of potential triggers that

might bring the pain as well as of his or her own pain-ful experiences and thus engages in various emotionalavoidance strategies (e.g., distracting himself or herselfwhen emotions arise) and behavioural avoidance strategies(e.g., avoiding situations in which the client could be criti-cized as is commonwith social anxiety). An interesting partof the dynamic is also the client’s self-treatment, by meansof which the client enhances his or her own control overthe triggering situation. This conceptual framework then in-forms which self-organizations (compassion and protectiveself-assertive anger) have to be facilitated to respond to thepain and unmet needs, so that they might transform the ex-perienced emotional pain. Individual aspects of the caseconceptualization framework contain a number of featuresthat we will describe in the sub-sections that follow.

Triggers

These are typically current, interpersonal situations thattrigger underlying painful, unbearable emotions (suchas feeling rejected, abandoned, overlooked and notresponded to). The triggers are actions or perceivedactions of significant others such as rejection (i.e.,exclusion, invalidation, humiliation, blaming, omissionand neglect). Often, the perceived triggers are current(e.g., a hurtful behaviour of spouse) but resemble thedevelopmental injuries from the time when the clientwas still developing and did not have resources to pro-cess the pain. Because the client’s emotional schematicprocessing does not lead to experiences and actions inwhich the client would be able to look after his or herown needs, the client resigns himself or herself to hope-lessness and/or helplessness.

Secondary Emotions—Global Distress

This is an aroused emotional state (see also Table 1) inwhich the client expresses a global form of emotional pain.(Note: the word secondary in the heading refers to a moresuperficial, undifferentiated levels of distress.) The client’spain embedded in the presenting issues often comes to thesurface very early in therapy. The attempt on the therapist’spart is to arouse emotional experience in order to be able to

follow a ‘pain compass’ (experiences that are most painful;Greenberg & Goldman, 2007; Greenberg & Watson, 2006)that might lead him or her to the underlying painfulemotions (core pain). In the secondary emotion stage, thoseunderlying emotions are often unclear. Rather, what ispresent is a global sense of hurt: undifferentiated sadness,pain, despair, hopelessness, helplessness etc. (‘I am tired,unhappy, I cannot cope anymore…’).Sometimes, reactive anger may be present (‘How could he

do that? I hate him for it!’) or a mixture of anger and sadness(‘Why did you hurt me?’). This type of rejecting anger isoften more general and less articulate than assertivenessper se (see also Table 1; Pascual-Leone, Gillis, Singh, &Andreescu, 2013). It is often a defence against the underlyinghurt and in that sense may be somewhat easier to toleratethan to confront the deeper experience of core pain. Rejectinganger is characterized by a high reactivity to the other’s be-haviour and the sense that one is not in the control of theemergent feelings of anger. In this way, rejecting anger alsosometimes has a similar quality as the global nature ofdistress. Although the process model of Pascual-Leone andGreenberg (2007; Figure 1) distinguishes between globaldistress and rejecting anger as secondary emotions, thatdistinction may be less important from the perspective ofmost therapist’s case formulations. The exception to this willbe for client’s suffering from anger problems, for whom adetailed assessment of the qualities of rejecting anger mayhelp a therapist in helping the client to overcome entrenchedaspects of the anger expressions (Pascual-Leone & Paivio,2013; Pascual-Leone et al., 2013).

Negative Self-Treatment

Interestingly, in common with many before us (Greenberget al., 1993), we noticed that the interpersonal triggersinteract with the client’s self-treatment, the client’s ownway of relating to self. In developing case formulations,it is useful for therapists to notice that problematic self-treatment comes usually in two forms: one form is tryingto avoid painful feelings (see the discussion on EmotionalAvoidance, below) and another is somehow negativeabout the self. The usual presentation observed in de-pressed (Greenberg & Watson, 2006) and anxious clientsis one of self-criticism, negative self-judgement, self-contempt etc. It often appears in a more superficial way,e.g., the client is critical of self because of being depressed(‘You should not be depressed’). This critical response toone’s own problems is typically an expression of a morecore negative self-judgement, e.g., ‘something is wrong withme, I am flawed.’ The concept of self-criticism is similar tocore dysfunctional self-beliefs in cognitive therapy (Beck,Rush, Shaw, & Emery, 1979), although in EFT we empha-size the process (experiential) aspects of the negativeself-treatment, not only the content of the belief.



Table1.

Key

emotionpresen

tation

san

dthetherap

ist’s

treatm

entof

them

Emotion

Verba

lexp

ression

Non

verbal

expression

Func

tion

ofem

otion

The

rapist’sworkwith

emotion

Globa

ldistress

E.g.,‘Iam

overwhelm

ed’,‘I

amtired,u

nhappy,I

can’t

cope’,‘Ifeelhopeless,

helpless’,‘Iam

anxious,

irritatedhu

rt’…

Pain,h

urt,crying

,signs

ofdespa

ir,h

opelessnessan

dhe

lplessne

ss,g

eneral

unha

ppinessan

dglob

alsadn

esssuch

asresign

ation,

low

energy

andexpression

sof

beingdow

n;also

mixturesof

feelings,

particularly

ange

ran

dhu

rt,irritab

ility,signs

ofan

xiety(ten

sion

s,bo

dily

ache

s),p

hysicalten

sion

s,ph

ysical

tiredne

ssetc.

Emotiona

larous

almay

beve

ryhigh

.

Second

aryem

otions

that

aretypically

aresp

onse

totheun

derlyingprim

ary

emotions

such

assham

e,fear

andsadn

ess/lone

liness.

Sincetheprim

aryem

otions

aretrun

catedor

dono

tlead

toad

aptiv

eactio

n,theclient

‘resigns’tosecond

ary

emotions.

The

therap

ist

ackn

owledge

sglob

aldistress,expresses

empa

thyab

outitbu

ttries

todifferen

tiateitby

focu

sing

onthemore

underlyingan

dprim

ary

emotions.

Rejecting

ange

rE.g.,‘Ihate

you!’,‘H

owcouldyoudo

that?’,‘Youare

disgustin

g!’

Physical

sign

sof

rage,(e.g.,

loud

voice,

clen

ched

fists,

jaws,teeth,

angrylook

and

threaten

ingbeha

viou

r).

Sometim

es,rejectin

gan

ger

ismixed

with

hurt/

sadn

ess.

Theclient

isve

ryreactiv

eto

theaspe

ctsof

theothe

r’sbe

haviou

ran

ddo

esno

tha

veasenseof

beingin

controlo

fow

nan

ger.Em

otiona

larousal

isve

ryhigh

.

Func

tion

ally

equiva

lent

toglob

aldistress.Thisis

undifferentiatedan

d/or

second

aryan

gerthat

may

also

serveas

adefen

ceag

ainsttheun

derlying

hurt

andvu

lnerab

ility.

The

therap

ist

ackn

owledge

sthean

ger

andeither

focu

seson

underlyinghu

rtor

triesto

form

itinto

amore

assertivean

ger,on

ethat

isno

tas

reactive

andothe

r-oriented

.Fo

rclientswho

have

difficu

ltyin

accessingan

yan

ger,

accessingthis

canactually

beprod

uctive

.Doing

sogive

sclientspe

rmission

tobe

angryas

they

are

learning

toaccess

and

expressan

ger.The

long

erterm

goal

isto

express

ange

rin

amoread

aptive

andsymbo

lized

form

with

outa

ttacking

theothe

r.Anticipatoryan

xiety(fear)

E.g.,‘Iam

anxious’,‘Ifeel

panicky,

tense.’

Physical

symptom

sof

panican

dan

xietysu

chas

restlessne

ss,ten

sion

,stom

achup

setan

dirritability.

Worries,

scan

ning

theen

vironm

ent

forthreat.E

motiona

lexpression

isob

structed

.

Func

tion

ally

differen

tfrom

prim

aryfear

(see

below).App

rehe

nsionthat

lead

sto

emotiona

lav

oidan

ce(e.g.,worrying,

self-m

edicatingan

dself-

distracting)

andbeha

viou

ral

avoida

nce(e.g.,av

oiding

feared

situations).

The

therap

ist

ackn

owledge

san

xiety,

may

workwithsymptom

sto

offersome(sup

erficial)

soothing

,ifan

xiety

othe

rwiseinterferes

with

therap

euticwork.

Ultim

ately,

thetherap

ist

aimsto

help

aclient

overcomeav

oidan

cean

dthereb

yseetheob

structions

anxietycauses.T

herapists

(Contin

ues)



Table

1.(C

ontinu

ed)

Emotion

Verba

lexp

ression

Non

verbal

expression

Func

tion

ofem

otion

The

rapist’sworkwith

emotion

facilitateworking

throug

hthisde

bilitatingan

dob

structingan

xiety.

Sham

e(incore

pain)

E.g.,‘Iam

flaw

ed,w

orthless,

defective,sm

all’,

‘Ideserveto

bemistreated.’

The

action

tend

ency

ofthis

sham

eis

tohide,

shrink

anddisap

pear,w

hich

prod

uces

aclient’s

presen

tation

that

may

beslow

,broke

nan

doften

interrup

ted.G

azemay

bedirecteddow

n(toav

oid

beingseen

).The

client

may

have

asenseof

shrink

ing

orfeel

physically

sick.T

hefeelingmay

beoccasion

ally

subtle,b

utve

ryun

comfortab

lean

dall

consum

ingas

ifitisne

ver

goingto

goaw

ay.

Emotiona

larous

almay

vary,a

ndthis

emotion

oftenpresen

tswithothe

rem

otions

such

assadne

ssan

dfear.

Thisis

aprim

ary

expe

rien

ceof

being

rejected

,jud

gedan

dan

outcast.The

need

tobe

recogn

ized

,ackno

wledg

ed,

seen

andresp

ectedis

violated

.

The

therap

isthe

lpsthe

client

stay

withthesham

e,rather

than

avoidit.T

hisis

carried

outby

helping

aclient

toarticu

late

aspe

cts

ofit,p

articu

larlyan

yun

met

need

sto

beseen

,va

lued

,recog

nized,

resp

ectedetc.

Sadne

ss/lone

liness(incore

pain)

E.g.,

‘Ifeel

empty,

onmy

own,

lonely’,

‘Iam

alone,

missing

him/her’etc.

Cryingan

dfeelingavo

idthat

something

ismissing

.Lon

ging

forcomfort.L

owan

dtend

ervo

ice,

look

ing

dow

nan

dothe

rtypical

sign

sof

sadne

ss.T

heclient

may

also

show

sign

sof

hope

lessne

ssan

dresign

ation,

such

asbo

wingon

eshe

ador

having

ones

shou

lders

dow

n.Emotiona

larous

almay

behigh

.Emotion

oftengo

eswithothe

rcore

emotions

such

assham

ean

dfear.

Thisis

aprim

ary

expe

rien

ceof

being

disconn

ected,a

band

oned

ormissing

theothe

r.The

unmet

need

that

isbe

ing

sign

alledhe

reisane

edfor

love

,com

fort,c

are,

look

edafter,forconn

ection

,closen

essetc.

The

therap

isthe

lpsthe

client

notto

defl

ector

avoidthefeelingbu

trather

toarticu

late

differen

taspe

ctsof

lone

linessan

dsadne

ss.

The

aim

isto

help

aclient

torecogn

izethat

the

feelingem

bodies

impo

rtan

tne

edsfor

closen

essan

dconn

ection

orsu

pporta

ndcare,w

hich

thetherap

istalso

helpsthe

client

toarticu

late.

Prim

aryfear

(incore

pain)

E.g.,‘Iam

scared,terrified’,

‘Iam

falling

apart,loosing

myself’.

Acu

tefear,d

issociations,

derealiz

ation,

dep

ersona

lization,

acute

uncomfortab

leph

ysiologicalu

pset

and

physical

symptom

sof

losing

controlo

veron

e’s

ownbo

dy.Emotiona

larou

salm

aybe

high

.Emotionoftengo

eswith

Thisaprim

aryexpe

rien

ceof

beingintrud

ed,inv

aded

orfalling

apart.In

contrast

toan

ticipa

tory

anxiety,this

isno

tafear

ofwha

twill

come,

butrather

itis

anexpe

rien

ceof

sheerterror

andup

set.The

action

tend

ency

isto

immed

iately

The

therap

ististrying

tohe

lptheclient

tobe

able

tostay

withthisfear

and

have

asensethat

theclient

ismorethan

fear

andthat

thefear

canpa

ss.T

hetherap

istisalso

trying

tofacilitatetheclient’s

articu

lation

ofthene

edsin

thefear

expe

rien

ce,the

(Contin

ues)



Table

1.(C

ontinu

ed)

Emotion

Verba

lexp

ression

Non

verbal

expression

Func

tion

ofem

otion

The

rapist’sworkwith

emotion

othe

rcore

emotions

such

assham

ean

dsadne

ss.

escape

(not

just

toav

oid)

dan

geror

distress.

need

forsafety,security,

protection

etc.

(Self-)com

passion

E.g.,‘Iam

here

foryou’,‘I

love

you’,‘Icare

aboutyou’

(tow

ardstheself).

Warm

feeling,

typically

directedto

theselfin

the

imag

inarydialogu

es.

Feelingfille

dwithlove

,caring

,asenseof

warmth,

beingmov

ed,som

etim

eswithatouc

hof

sadne

ssan

dpa

in.P

ossiblysensing

relie

fan

dease.

Thisfeelingisge

neratedas

anad

aptive

resp

onse

tothe

unmet

need

sem

bedded

incore

pain.Ith

asasoothing

,calm

ingan

dhealingqu

ality.

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istfacilitates

thisfeelingby

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client

access

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nerate

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ssion,

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itan

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lize/

expressitfully

.The

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istalso

helps

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toreceivethis

compa

ssion,

expe

rien

cean

den

joyitsim

pact

(often

lead

ingto

relie

f).

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(assertive

)an

ger

E.g.,‘Ideserved

your

care’,‘I

feelstrong

,pow

erful’,

‘Iam

settingtheboun

dary’.

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orting

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gth.

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sturemay

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righ

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heclient

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reactant

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rtfulo

thers/

situation.

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func

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ofprotective

(assertive

)an

geris

tomob

ilize

resp

onse

tothe

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need

sin

core

pain

andto

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idesu

pportfor

oneself.Itis

asource

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rson

alpo

wer

and

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confi

den

cethat

undoe

sthehu

rt.

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istfacilitatesthe

gene

ration

andexpression

ofprotective

ange

ras

aresp

onse

toun

derlying

hurt

and

unmet

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sen

taile

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it.T

heaim

isto

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aclient

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nerate

andsu

stainan

assertive

stan

ce.

Grief

E.g.,‘Itissadthat

Ihad

togo

throug

hallof

this,bu

tit

isnotdistressingmethat

muchanym

ore.’

The

feeling

ofsadne

ssis

difficu

ltbu

talso

brings

asenseof

calm

ness

andrelief.

The

emotionha

san

acceptingan

dun

derstand

ingqu

ality

.This

mustb

edistingu

ishe

dfrom

sadn

ess/

lone

linessin

core

pain,w

hich

ismuc

hmore

upsetting

.The

client

may

cry,

butthe

searethetearsof

sadn

essan

dun

derstand

ing

rather

than

hope

less

protest

orpa

in.

Thisrepresen

tsthelater

stag

ead

aptive

grief.Itha

saletting-go

quality;

the

client

isno

long

ertortured

bytheloss

buton

the

contrary

isacceptingof

it.

The

client

may

still

recoun

thu

rts,which

,althou

ghstill

difficu

lt,do

not

have

that

torturing

andup

settingqu

ality.

The

therap

istwelcomes

adap

tive

griefas

asign

that

theclient

isprog

ressingin

therap

yan

dthat

core

pain

hasbe

entran

sformed

.The

therap

ist

prov

ides

empa

thic

follo

wingan

dpe

rhap

sshares

hisor

herow

nexpe

rien

ceof

witne

ssing

theclient’shu

rtan

dtran

sformation.

Emotiondescription

isinform

edby

theoriginal

measu

remen

tcriteria

ofPa

scua

l-Leo

ne&

Green

berg

(2005).



Negative self-judgement is often an introjected criticismfrom significant others (Kannan & Levitt, 2013). However, itcan also be a conclusion drawn by the client in childhood,which provides some explanation as to why a significantother was hurtful (‘I deserve rejection, humiliation, exclusion,judgment—something in me is unlovable, etc.’). We hypothe-size that this type of conclusionwas developmentally usefulas it attributed the responsibility for the adverse treatmentto the client and thus allowed him or her to have some senseof control over the otherwise unpredictable and hurtfulbehaviour of the other. Therapists can often observe this,when they gather experientially vivid personal history fromclients, based on poignant memories.The interplay between painful interpersonal triggers

and a client’s self-treatment is complex. The client triessomehow to make the hurtful triggers controllable. How-ever, he or she does it in a punitive way that paradoxicallycontributes to one’s distress (Pascual-Leone et al., 2013).For many clients, however, this type of harsh self-treatment is not only negative but also contributestowards behaviour that brings them ‘positive’ reactionsand appreciation from others (Kannan & Levitt, 2013). Itmay therefore also have an important self-protective(albeit maladaptive) function. Examples of such self-treatment can be visible through messages such as ‘Benicer towards others so they will like you’, ‘Work hard so youwill achieve and be appreciated’ and ‘Prepare yourself forpotential danger’.

Emotional and Behavioural Avoidance

Another form of self-treatment in which the client engagesis self-interruption (Greenberg et al., 1993) or emotionalavoidance of painful underlying feelings and behaviouralavoidance of situations that would trigger painful under-lying feelings. Emotional avoidance can take many forms.For instance, it is well described in cognitive–behaviouralliterature. It may be present in the numbing of feelings, thetightening of the muscles, intellectualizing and not payingattention inwards, dissociation etc. (cf. Barlow, Allen, &Choate, 2004). In cases of clients with generalized anxietydisorder (GAD) and similar anxiety problems, this maytake the form of worry (Borkovec & Roemer, 1995). Theclient may worry about what bad events may occur sothat he or she might prepare for the impact of events thatwould be unbearable. The worry is typically alsointertwined with behavioural avoidance, which means en-gaging in activities that reduce the likelihood of the fearedsituation (that would be unbearable; see, for instance, for-mulations from a CBT perspective Foa, Hembree, &Rothbaum, 2007).Despite the motivation to avoid the pain, the pain is not

resolved, nor is it alleviated in the long run. The avoidanceprevents the client from processing the underlying painful

emotions (see, e.g., Salters-Pedneault, Tull, & Roemer,2004) and thus from developing flexible emotion schemesthat would support greater maturity and resilience. Avoid-ance thus contributes to and becomes concomitant withglobal distress, contributing to hopelessness/helplessnessand an undifferentiated sense of distress and pain.

Anxiety and Apprehension

The anticipatory fear of situations that might evoke pain-ful emotions as well as fear of actual painful feelingsdrives the client’s emotional and behavioural avoidance.This fear has to be distinguished from a more primary fear(see core pain, below), which may be experienced intrauma and has more of a ‘terror’ quality (see also Table 1).Anticipatory fear is a main presenting feature of anxietydisorders. For instance, in social anxiety, the fear of a so-cial situation is self-evident, but this is not the core painfulprimary emotion. Rather, the core underlying emotion iscentred on the shame of humiliation (cf. Shahar, 2013).The anticipation of shame (of being ridiculed, negativelyevaluated and humiliated) is played out on the surfacein the form of anxiety. This anxiety then leads, forinstance, to behavioural avoidance of social situations.This distinction is crucial for case formulation becauseEFT, does not focus on this anticipatory anxiety butprimarily on the core painful emotion, which in this caseis shame. Although the anticipatory fear has a protectivefunction and prevents a client from feeling the underlyingpain, it also prevents successful and healthily flexibleemotional processing.

Core Emotional Pain

Core pain is the underlying primary painful emotionalresponse to the triggering situations or perceptions. Thiscore emotional pain is present in the form of discreetprimary painful emotions (Greenberg & Safran, 1989;Greenberg, 2011) that are fundamental responses to theclient’s unmet needs in the triggering situations. We usethe term ‘core’ in this paper to highlight that these painfulemotions are the ones that the therapist focuses on. Theyare in the centre of problematic emotional self-organizations (schemes) and need to be either workedthrough or transformed in therapy.The core emotional pain consists of unbearable emo-

tions that are personally devastating to the client and of-ten affectively overwhelming. This is why clients oftencollapse into global distress, in which discreet emotionsare buried by more secondary feelings of hopelessnessand helplessness of not having the needs in the core pain-ful emotions met. The studies investigating core emotionalpain in depression (Greenberg & Watson, 2006), complex



trauma (Paivio & Pascual-Leone, 2010) and anxiety(O’Brien et al., 2012; Shahar, 2013) suggest that core emo-tional pain centres around shame-based, loneliness-basedand fear-based experiences. Still, it may be helpful to rec-ognize that authors differ somewhat in their formulationof this (e.g., Greenberg and Watson [2006] and Paivioand Pascual-Leone [2010] emphasize the maladaptive na-ture of shame-based and fear-based emotional experiencesas being the more fundamental experience when it comesto unhealthy experiences of loneliness/sadness; see alsothe original work of Pascual-Leone and Greenberg [2007]that linked loneliness to other maladaptive emotion;namely the shame of being alien or the fear of being aban-doned, i.e., attachment insecurity).Shame-based emotions are emotional experiences that in-

corporate an action tendency to hide, shrink, disappearand narrative messages such as ‘I am flawed, worthless’and ‘I deserve to be mistreated’ (see also Table 1). They areresponses to internal or external situations of rejection,judgement, humiliation etc. They can also be a responseto negative self-treatment (e.g., ‘I deserved to be bullied,because I was weak’). This is particularly apparent in self-hate or self-loathing (Pascual-Leone et al., 2013). Even so,the embedded need in those experiences is to be ‘valued,appreciated, recognized, accepted, etc.’Loneliness-based emotions are emotional experiences of a

profound isolation and loss of connection (e.g., loss ofloved one; see also Table 1). However, there remains somedebate as to whether loneliness as a form of core pain isultimately most problematic on account of it beingassociated with concomitant feelings of shame or fear(Greenberg & Watson, 2006; Paivio & Pascual-Leone,2010; Pascual-Leone & Greenberg, 2007). For the purposesof case formulation, the defining unresolved emotionaldifficulty that is important here is sadness and a chronicsense of missing connection, missing the caring presenceof the other, or missing the presence of a vulnerable otherthat the client cared for. In narrative, loneliness shows inexpressions such as ‘I feel empty, on my own, alone, lonely’.Loneliness and sadness are typically responses to situa-tions of exclusion, loss of loved one, the situations inwhich the person is overlooked, neglected (as a child),not supported or not cared for etc. The embedded unmetneeds in those experiences are the needs ‘for closeness,support, love, connection, etc.’Fear-based emotions (Table 1) include experiences of

terror, acute fear, dissociations from horrifying or over-whelming affective experiences etc. They include experi-ences of physiological and psychological upset, in whichthe client does not have control over the situation. Theaction tendency is to escape from danger or distress. Inpsychotherapy, these emotions appear in the form of theactivation of a traumatic experience. Needs in these typesof experience that remain unmet or unresponded toinclude a need for ‘safety, protection, stability, etc.’

Ultimately, core emotional pain usually consists of amixture of shame-based, loneliness/sadness-based andterror/fear-based emotions. For each person, the coreemotional pain will consist of several idiosyncratic varia-tions of these emotions. The core emotional pain is anunderlying vulnerability that builds on the injuries andpainful experiences, often occurring at early developmen-tal stages in the client’s life. The lived experience of thisvulnerability is that the client had insufficient strength toprocess or adequately cope with life circumstances. Thisis due to the natural vulnerability of childhood and therelative lack of support from caregivers and may likelybe related to a client’s genetic vulnerability to psychopa-thology (cf. Way & Taylor, 2011). The core emotional painis activated, when the client experiences situations similarto the original emotional injuries. Core emotional pain canbe similarly activated through identifying with the pain ofothers (whether this be ‘real and accurate’ or projected orboth). This is especially so, if the painful emotions areobserved in dependant others such as one’s own children.The core emotional pain is the focus of treatment. The

core experience in the scheme needs to be processed andtransformed, allowing the client to be not entirely con-sumed by shame, loneliness or fear. The client becomesmore resilient by moving more easily to experiences ofself-assertion (i.e., strength and affirmation), self-compassion,and also of adaptive grief, when confronted by situationsthat previously triggered the core pain. The first step intherapy is to go beyond the global distress and avoidanceto ensure that core painful emotions are accessed. Sec-ond, these core emotions must be regulated and madebearable enough to allow therapists and clients tocollaboratively articulate the needs embedded in painfulclient experience.

Needs

Studies of EFT for depression, trauma and anxiety suggestcertain types of needs to be associated with certainclusters of primary and painful emotions. The needsentailed in shame-based emotions include, for instance,the need to be appreciated, respected, accepted, acknowledged,recognized, seen, validated etc. The needs embedded inloneliness-related emotions include, for instance, the needto be reached out to, connected to, loved, cared for, includedand also the need to love, to reach out to, connect, to carefor, to include etc. The needs embedded in terror/fear-related emotions include, for instance, the need for safety,for control, for mastery, for personal strength etc.These needs are primary existential (basic) needs of the

person (Pascual-Leone & Greenberg, 2007). The appraisalof the person’s environment in relation to their needs isexpressed in one’s emotional experience (Greenberg,2011). This emotional pain informs us that we appraise



our fundamental needs (i.e., for survival, love and mas-tery) as not being sufficiently responded to or fulfilled.The fact that this lived experience of interaction with theenvironment does not provide an adequate fulfilment ofthe need, brings pain, which in turn leads to resignationin clinical cases: global distress (e.g., in the form ofhopelessness and helplessness), fearful apprehension oravoidance of triggers that may remind one of not havingone’s needs met.

Facilitating Emerging Adaptive Emotions

Initially (see phase 1 in Figure 2), the therapist uses theoutlined case conceptualization as a framework to informhis or her understanding of the dynamics related to aclient’s distress. This framework helps to orient thetherapist in the client’s experiencing and informs the ther-apist’s actions that focus on highlighting the triggers andself-treatment, overcoming avoidance and focusing onthe underlying core painful emotions. These are then fur-ther differentiated and unmet needs in them are articu-lated (see phase 2 in Figure 2). All of it is happening inthe context of an empathic, caring and soothingrelationship.Once core pain is fully accessed and unmet needs are

fully articulated, the therapist can facilitate the client’scompassionate response to these needs (see phase 3 inFigure 2 and also Table 1). In EFT, this is sometimesachieved by a therapist’s compassionate response to theclient and through the validation of the need (‘I can senseyour pain and so much want you to feel cared for’). However,self-compassion is also achieved through experientialtechniques that may allow the client to generate his orher own compassionate responses. For instance, using animaginary empty-chair dialogue, the client could enactsome remembered caring other or enact his or her current(adult) self and respond to the heart-breaking pain andunmet needs expressed by the (usually younger) self,who was hurt, ashamed, lonely or scared.Similarly, assertive and protective anger is generated in

well proceeding EFT cases (see the phase 3 in Figure 2and also Table 1). Anger can again be expressed by thetherapist on behalf of the client (‘You deserved your parentslove’), but in EFT, it is seen as particularly important thatthe client himself or herself feels the anger in the moment.This is typically achieved through the enactment, in animaginary dialogue, of a situation in which the clientexpresses anger towards a harmful other (e.g., abusiveparent or peer bully).Several studies (e.g., Pascual-Leone & Greenberg, 2007;

McNally, Timulak, & Greenberg, 2014) observed that onceself-compassion and protective anger are generated andexpressed without reservation, a grieving process begins(see phase 3 in Figure 2 and also Table 1). This is a grieving

of what was (historically or currently) not met and whatcontributed to the development of the core painful emo-tional self-organization. It is as if the client were saying‘it is sad that I had to go through all of this, but it is notdistressing me that much anymore’.The enactment of compassionate and protective (self-

assertive) anger response to the unmet needs in corepain and its impact leads not only to grieving but alsoto a sense of emotional resilience, self-acceptance andempowerment (see phase 3 in Figure 2). Clients at thisstage feel confident. They may have a sense of personalmaturity, they are sensitive to their own hurt (and thusalso to the hurt of people around them), but do not feelscared of painful emotions (i.e., ‘I am alright, I canmanage, I am looking forward to things in life’). The studiesexamining the model presented in Figure 2 (e.g., Crowley,Timulak, &McElvaney, 2013; Keogh, Timulak, &McElvaney,2013; McNally et al., 2014) found, as was also in Pascual-Leone’s (2009) original work, that the progression acrossthe phases was non-linear and recursive with successfulcases eventually progressing more easily towards moreadaptive self-organization, despite occasional setbacks.

CASE ILLUSTRATION: ANN

We now illustrate the presented case conceptualizationframework using a case of brief (24 sessions) EFT. The cli-ent, Ann (pseudonym), was a woman in her early thirties,diagnosed with GAD. She consented to participate in a re-search project examining the efficacy as well as processes(including sessions analyses) involved in EFT (the client’scharacteristics and concerns are altered to protect confi-dentiality). Ann was referred by her physician becauseshe was highly distressed, and she generally rejected med-ication. Her presenting symptoms were that she worriedconstantly, did not sleep well and frequently became soagitated that she was literally unable to sit with her anxi-ety, moving around the house. Her worries concernedthe well-being of her children and her husband. She wassometimes overprotective of them, over-involved in theirlives and often trying to control anything bad that couldhappen to them. For example, she anxiously phoned themwith great frequency and was constantly checking herphone in session. She also worried about her own physicalhealth (her brother had died of an unexpected illness ather age). She was also very critical towards herself,harshly blaming herself for her own difficulties.Her initial score on the main measures of anxiety puts

her clearly in the clinical range (on the GAD-7 scale;Spitzer, Kroenke, Williams, & Löwe, 2006; GeneralizedAnxiety Severity Scale; Shear et al., 2006—Table 2). Onthe measure of depressions (Beck Depression Inventory-II; Beck, Steer, & Brown, 1996), her score was 12, whichseemed under-reported given that in addition to meeting



criteria for GAD, she also met criteria for major depressivedisorder as assessed by the Structured Clinical InterviewDiagnosis-I/P (First, Spitzer, Gibbon, & Williams, 2002).She also completed the Structured Clinical InterviewDiagnosis-II (First, Gibbon, Spitzer, Williams, & Benjamin,1997) assessing personality disorders (DSM-IV-TR AxisII), which indicated that she met the diagnostic criteriafor avoidant, obsessive–compulsive and depressive per-sonality disorders. Overall, she made a good progress intherapy as indicated by the principal outcome measures(Table 2).Ann’s therapist was one of the authors of this paper.

Although the original process model by Pascual-Leoneand Greenberg (2007; Figure 1) shaped the therapist’sthinking about this case, we now present a case conceptu-alization of Ann using Figure 2, the approach that wasbeing formed at the time when Ann was in treatment. Insession, the therapist focused on the differentiation of corepain, how that pain was triggered or sustained, andunmet needs. The therapist also focused on facilitatingadaptive emotions that would undo the core painful emo-tions. This thinking supplemented the traditional focus ofEFT on in-session markers as well as the emphasis on theelaboration of identity as well as attachment-relatedexperiences (Greenberg & Goldman, 2007). This modifiedapproach to case conceptualization is illustrated in thesub-sections that follow. In this approach, clinicians canfill in the figure’s boxes with details from session notes,and Figure 2 shows notes specifically related to the caseof Ann.

Triggers

The most current triggers that brought upset and unbear-able anxiety for Ann were situations in which she couldnot protect herself, or loved ones, from a potential danger.Dangerous situations were mainly health concerning situ-ations (e.g., asthma of her daughter or her own health).The therapist explored the client’s narrative and the

poignant memories that contributed to her emotionalpain. She had felt very much on her own as a child, sinceshe was neglected and often attacked by her own mother.For instance, she had to hide in fear, when her motherdrank too much and became angry and verbally abusive.Finally, she was traumatized when her mother died sud-denly when she was just 9 years old. Around that time,Ann was afraid that she would lose more people fromher family and that she would become even more lonelyand abandoned than she already felt.

Self-Treatment

Ann was quite self-reproaching and self-contemptuous.She blamed herself for her difficulties and accused herselfof ‘moaning too much’. In the initial imaginary chair dia-logues, Ann clearly indicated that she did not deserveany compassion and, indeed, had a great difficulty inexpressing anything resembling self-compassion (note:structured imaginary dialogues with significant others orparts of self are typical EFT interventions; Elliott et al.,2004). On the contrary, she hated her own vulnerabilityand despised the need for a more compassionate and sup-portive treatment. She also took on any responsibility forthe suffering of those close to her. Indeed, it was ‘her job’to prevent any harm to her loved ones. She was able toinstil tremendous guilt in herself, if anything went wrong.

Secondary Emotions—Global Distress

The client presented with a pervasive sense of global dis-tress. She would cry very easily and has high emotionalarousal. When highly emotional, she made little eye con-tact and had difficulty engaging in dialogue. As a result,the therapeutic alliance was initially quite strained on ac-count of the client feeling so hopeless and distressed thatshe could not see how anything could help.Ann was particularly upset when those close to her

found themselves in situations where they could be

Table 2. Pre–post outcomes of the illustrative case

Scale Caseness RCI Pre-treatment Post-treatment 6-month follow-up

GAD-7 10 4 19 8 8GADSS 7 n/a† 19 6 5BDI-II 10 9 12 4 2PSWQ 46 9 78 51 42CORE-OM 1.29 0.48 1.32 1.12 0.94

Note: We used caseness and RCIs as reported in the literature or we calculated it from the available data (Beck et al., 1996; Behar, Alcaine, Zuellig, & Borkovec,2003; Craske et al., 2011; Evans et al., 2002; Gyani, Shafran, Layard, & Clark, 2013; Seggar, Lambert, & Hansen, 2002; Spitzer et al., 2006).Caseness = the cut-off for determining whether client is clinically distressed. RCI = reliable change index. GAD-7 =Generalized Anxiety Disorder–7.GADSS =Generalized Anxiety Disorder Severity Scale. BDI-II = Beck Depression Inventory. PSWQ=Penn State Worry Questionnaire. CORE-OM=ClinicalOutcomes in Routine Evaluation—Outcome Measure.†The RCI was not reported in the literature nor the data that would allow its calculation.



harmed, mistreated, neglected etc. Similarly, she becameeasily upset at the thought of losing anybody close. Withregard to the developmentally decisive triggers, she wasupset by thoughts of her mother. In the initial imaginary(empty-chair) dialogues with her mother, the client wouldbe either in a state of undifferentiated upset or reactangrily and then feel bad and hopeless about the fact thather mother had not been there for her as a child.

Emotional and Behavioural Avoidance

The main feature of the client’s emotional avoidance washer worry process. She worried that something bad wouldhappen to her children and that they would suffer physicalpain and feel desperate and isolated while dealing withdifficult situations. The worry process was intensified bycontrolling behaviour (a form of behavioural avoidance)that attempted to minimize potential difficulties that herloved ones might encounter. She felt responsible for any-thing that might lead to another (traumatic) loss for her.Another form of avoidance was her agitation that escalatedwhenever she was confronted with a difficult life situation.The agitation kept her engaged in problem solving andprevented her from staying with the imagined conse-quences of the situation.

Anxiety/Apprehension

Anxiety was the most defining feature of Ann’s presenta-tion encompassing anticipatory fear attached to manysituations, in which her loved ones would be exposed tosuffering, isolation, pain, upset and also the fear of herresponsibility for this. This anxiety fuelled her emotionaland behavioural avoidance. The anticipatory fear was alsopresent with regard to triggers of an older origin, when shewas scared to engage with the memories of her mother asshe found them too upsetting. She also felt that there wasa great deal of anger towards her mother, anger in whichshe felt bad about herself for feeling it. In turn, this anxietyabout her own emotions also influenced her self-treatment(e.g., self-interruption of anger; see top of Figure 2).

Core Emotional Pain

The client’s underlying core painful feelings centred on aprofound sense of loneliness, shame and traumaticterror/fear. Ann felt very alone, particularly with regardto developmentally significant points in life. The loneli-ness pertained to her feelings of not having had a motherpresent when she needed her (‘I had nobody to turn to’) aswell as to the fact that the mother ’s premature deathprevented her from improving that relationship, leadingto a long-lasting loss and the absence of motherly support

in her life; e.g., ‘I had nobody to help me when my own kids weresmall.’ Indeed, being unsupported and afraid was a salienttheme of her personal history. Ann felt unsupported andoverwhelmed by the responsibility of looking after ownchildren and trying to keep them out of harm’s way andshelter them from the suffering she had endured as a child.Ann’s sense of shame was particularly connected to the

‘embarrassment’ of her mother who was ‘a drinker ’. She par-ticularly remembered how her mother ‘ruined her birthday’,because she got so drunk:

all this, all these relatives… and we came out of the res-taurant… and the smell of drink on her… she fell twice....So, that’s my earliest memory… Other kids’ mothersaren’t like that.

She also expressed how she wished for her mother to bedifferent: ‘Every day there was hope that she wouldn’t bedrinking.’ Ann even asked her mother to stop but wasattacked and invalidated: ‘I asked you to stop and thenyou made it out that it was all my fault’ (the first person in-dicates that this statement was expressed in an imagi-nary chair dialogue). Indeed, the invalidation led Annto believe that somethingwaswrongwith her, given thatmom kept blaming her, and because deep down Annfeared she was like her mother: ‘I’m afraid I’ll end up likeher.’ This corresponded with her negative self-treatment,in which she made clear that she did not deserve a goodtreatment and that all her problems were her own fault.The terror/fear aspects of Ann’s core pain probably had

their origins in the intrusive and invalidating attacks fromher mother as well as her mother ’s subsequent, suddendeath. These traumatic aspects of her personal narrativewere linked with the sense of abandonment and shame.Attacks that powerfully show the client’s adverse experi-ences are visible in her memories of being,

worried when I was a kid going home, and seeing whatmood my Mom was in. If she’s going to be ranting andraving, or what. You just didn’t know what was goingto happen when you walked in through the hall door…nine times out of ten it would be anger.

The sense of an impending, unpredictable and terrifyingevent was further worsened by the sudden death of hermother. She knew what catastrophe felt like and how itmight deepen her loneliness even further.

Needs

The needs embedded in core emotional pain crystallized asthe therapy progressed. The client had great difficulty ex-pressing and owning that which her vulnerable experiences



suggested she needed. This was connected to her negativeself-treatment, in which she harshly and contemptuouslyjudged any need as selfish, implying that she was flawed,needy and mean. However, in the context of a compassion-ate and supportive alliance and in heart-breaking poignantdialogues with her imagined mother, children and hus-band, the client was eventually able to clearly articulateand express: her need for connection and support (‘I neededand deserved to have a mom that cared for me’); her need foracknowledgement and validation (‘I needed to hear that thereis nothing wrong with me and I deserved to be supported’); herneed for safety (‘I needed to be spared from attacks andtraumas’); and her need for protection aswell as her determi-nation to face the adversity (e.g., the most feared situations:‘I do not want to be hiding. I want to live freely’).

Strategy for Therapy Informed by CaseConceptualization

Different parts of this case conceptualization interplayedwith each other (Figure 2). The therapist’s understandingwas further formed through the client’s emerging narra-tive, particularly to the extent that this was anchored inobservations during the experiential enactments in imagi-nary chair dialogues. Triggers in everyday life broughtcore pain, which was, however, not possible for Ann toprocess and she continually collapsed into global distress.While in a state of global distress, she further blamed her-self for the distress and vulnerability and for her ‘defective’core-self. Ann was trying to avoid distress and pain, bymanaging and controlling triggers and subsequent experi-ences of the core pain. This happened in her everyday life,and it was also clearly visible in the treatment sessions.The departure point of therapeutic work was to enact trig-gers, typically through vivid imaginary dialogues withthe relevant people from Ann’s life (mother, children, hus-band etc.) and the critical and interrupting parts of herself.The emerging case conceptualization informed therapy

in several ways. The therapist’s first task, after buildingan alliance and trying to help Ann regulate the strongemotional arousal she had in session, was to help differen-tiate her underlying pain. This was pursued by empathic-ally evoking and exploring painful situations, initially, thecurrent situations and then later on those based on mem-ories of events that formed the core pain. Although tradi-tional EFT tasks (Elliott et al., 2004) were used as well, theywere re-conceptualized as tools allowing evocation (andthe eventual transformation) of core pain.Access to core pain was difficult mainly because Ann of-

ten collapsed into global distress, whenever her core painwas touched on (a dynamic process in the model de-scribed by Pascual-Leone [2009]). When she collapsed,the therapist responded with compassionate empathic in-terventions, and also through interventions intended to

calm the client such as clearing a space (an EFT interven-tion similar to mindfulness; Elliott et al., 2004), whichhelps clients to put their upsetting and overwhelming is-sues aside for the moment.Experiential engagement with Ann’s core pain was

also obstructed by emotional avoidance. Avoidanceprocesses were mainly visible through the constantworry that both flooded and was exhausting for theclient. This process was eventually counteracted bythe client’s need for rest, her awareness of the impactof her worry (i.e., feeling tired), the need to be freeand playful and finally through the protective (self-assertive) anger (see the lower part of Figure 2) thatopposed the worry process (‘I have had enough of you’).Again, traditional experiential tasks such as self-interruption (Elliott et al., 2004) were typically used for thatpurpose. However, these tasks were re-conceptualized aswork on avoidance with the added understanding thatapprehensive anxiety and vulnerability of core pain werecentral motivators driving the avoidance. In short, avoid-ancewas conceptualized as a broader phenomenon ofwhichself-interruption was only one example.Once core pain was accessed, it was important to put

it into language through empathic responding as wellas through a sustained effort to help the client to staywith it

(e.g., Therapist: ‘Breath. Just see how loneliness feels. Trynot to run away from it. You are more than that emptysense inside. It is just a powerful feeling. If you were toput it into words how does it feel? Speak to your mom[imagined in the other chair] from that loneliness.What do you say to her?’)

. The next step was to help Ann to articulate her unmetneeds, embedded in core painful emotions. When thecore painful feeling was fully unfolded, the therapistasked Ann: ‘What is it that you needed? What is it thatyou need when you feel so profoundly lonely?’ She wouldthen gradually articulate her needs (e.g., ‘Every girlnow-and-then needs her mom. I needed a mom’). The workon Ann’s capacity to stay with underlying and con-suming loneliness, shame and trauma-related fearshowed gradual progression over the course of ther-apy. The client became capable of staying longer andlonger with those experiences before collapsing intoglobal distress as predicted by the emotion transformationmodel and its recursive nature (Pascual-Leone, 2009). Annalso became graduallymore capable of putting the experi-ence into a detailed narrative and quicker in identifyingher needs. This gradual progression in being able tofeel and stay with the pain was understood throughthe lens presented here in the model.



When the unmet needs were fully expressed, the thera-pist tried to see whether Ann was capable of enacting acompassionate response to those needs (see ‘Compassion’,lower part of Figure 2). This would sometimes be carriedout by asking Ann to enact a responsive other she remem-bered (i.e., her husband and dad). At other times, thetherapist probed for whether Ann would be able to becompassionate as an adult towards the more vulnerableaspects of her own painful childhood experiences, whichshe enacted in session during imaginary dialogues. Alter-natively, the therapist would explore whether Ann, whenenacting her mother in an imaginary dialogue, couldimagine her mother actually being responsive to theheart-breaking hurt that Ann had felt as a child. All ofthese intervention strategies proved to be difficult, asany of Ann’s vulnerability was met with her usual self-contempt and the dismissal of unmet needs. However, astherapy progressed, Ann was more and more capable ofenacting and expressing compassion towards her ownhurt. She was gradually able to let in and accept thisexpressed compassion, which initially had been verydifficult for her. The work on promoting compassionwas pursued systematically (across sessions) on accountof the conceptualization described through the model,although traditional EFT tasks were still relied on as themeans for facilitating enactments of compassion. How-ever, these were used creatively and in a manner thatprioritized the generation of good quality experiences ofcompassion over actual task completion per se (as wasoriginally postulated by, e.g., Elliott et al., 2004).Accessing the anger (see ‘Protective anger’, lower part of

Figure 2) that Ann would use to support what she de-served in childhood was somewhat easier, although shecould easily get caught in the reactive and rejecting angerfor which she would blame herself (‘If I am angry at mymother, then I am an ungrateful daughter’). This healthyand protective (self-assertive) anger had to focus onsetting a boundary for her mother’s unresponsiveness(in imaginary dialogues) such as ‘I deserved to be cared forregardless what you say, it is just a fact.’ The client was ableto achieve that stance as a response to her mother ’s unre-sponsiveness, even though this was often followed by thesadness of not being loved and another collapse intoglobal distress. The work on boundary setting with regardto the mother ’s dismissal and unresponsiveness wasparalleled in the work on setting a boundary for the tiringand intrusive worry process. Eventually, the client becamefirmer and clearer in what she needed and in defining herperspective. Again, the work on promoting protective an-ger was informed by the conceptual framework presentedin this paper. The therapist carefully assessed the qualityof anger and promoted assertion and boundary settinganger. Many EFT tasks were used creatively for that pur-pose with the ultimate aim of helping the client generatea target emotional experience.

This sequence of emotional states centred not onlyaround the issues with her mother, her own self-contemptand her own avoidance but also around a variety ofsituations that she or her children were caught in. Thesesituations were typically enacted in session using chair di-alogues, in which Ann played out the common emotionalresponses of the characters in the events (Elliott et al., 2004;Greenberg et al., 1993). Through these imaginary dialogues,Ann was eventually capable of developing an increasinglyself-compassionate and protective (self-assertive) angerstance more easily following the expression of her painand the unmet needs embedded in it. She was also morecapable of ‘bouncing back’ and reorganizing quickly fromthe global distress and hopeless desperation into anempowering assertive anger. The process was far fromlinear and only slowly and painstakingly gradual, whichfits with the empirical observations made by Pascual-Leone(2009) about the change process often moving two stepsforward, one step back. The processmodel offered auseful ref-erence point for the therapist’s understanding and assessmentof the therapy over its session-to-session progression.She saw the therapy as successful, and her anxiety

(as measured by GAD-7 and GADSS) eventually movedinto a normal range. Towards the end of the therapy,Ann had a stronger sense of inner confidence that shewould be able to face issues that impacted either her orher loved ones. She was less upset about the neglect andmistreatment she experienced in her relationship withher mom. She had grieved what was not and what shouldhave been and did this with sadness that was notoverwhelming (again as expected by the model). Shewas finally capable of allowing her children to be inde-pendent, without becoming enmeshed in what they werestruggling with in their own lives. As her life becamericher, she found herself a new hobby (a yoga course at alocal community centre) and made time for herselfwithout feeling selfish and bad about it.

CONCLUSION

The case conceptualization model we have presented herecomplements the traditional EFT case conceptualization(Greenberg & Goldman, 2007; Greenberg & Watson,2006). Its main strength is that it is based on an empiricallyderived model of emotional transformation in EFT(Pascual-Leone & Greenberg, 2007; Pascual-Leone, 2009;Timulak et al., 2012) and that it can lead the clinical strategyand actions of a therapist working with her or his client.The strategy consists of several aspects:

1. Triggers. The therapist can note specific triggers thatbring the client to core emotional pain.

2. Self-treatment. The therapist can note how negativeself-treatment contributes to that core pain.



3. Secondary emotions—global distress. The therapist canbetter understand that the client is not able to bear thepain and how he or she collapses to global distress.

4. Emotional and behavioural avoidance. The therapist canunderstand that a client wants to avoid the pain andthe triggers that precipitate that pain.

5. Core pain. Thus, the therapist can try to help the clientin the context of caring relationship to overcomeavoidance and in being able to bear the emotional pain(i.e., shame, loneliness and/or fear) without collapsinginto despair and global distress.

6. Unmet needs. The therapist can aim at articulatingunmet needs that the pain signals.

7. a. Self-compassion. With the articulation of the unmetneeds, the therapist can aim to facilitate the client to expe-riences of (self)compassion that can be elicited throughwitnessing the heart-breaking quality of one’s own pain.b. Protective anger. The therapist can also facilitate theclient’s healthy assertive anger, usually through helpingthe client to highlight and enact the hurtful triggers thatlead the client to fight back and stand up for the self.

8. a. Grief and letting go. The process is then followed by agrieving of what happened and how hurtful it was, andthe client is finally able to ‘let go’ of unresolved pain.b. Empowerment and agency. At the same time, healthyanger at violation also brings the sense of empower-ment and personal agency.

The model presented herein highlights aspects of theclient’s perceptions, self-processes and emotional experi-ences that can inform a therapist’s understanding of clientsuffering and suggest actions to facilitate its transforma-tion. The usefulness of this approach should be examinedusing empirically based case studies of transformation(e.g., McNally et al., 2014; Kramer et al., 2013). It wouldbe also interesting to examine whether therapists usingthis model could increase their effectiveness in therapy.On a more cautious side, it remains to be seen whetherother theoreticians will find the model presented here asuseful in organizing their understanding of their clientsand in guiding their strategy for the work with clients.As the model was developed on the basis of process re-search on clients, primarily with mood and anxietydisorders (although with co-morbid trauma, chronic life-threatening illness and co-morbid personality disorders),it remains to be seen whether it will be a useful organiz-ing framework for other presentations.The model we present shares some characteristics that

can be found in other theoretical approaches to caseconceptualization. For instance, with psychodynamictherapies, it shares its focus on underlying motivesin behaviour (wishes in psychodynamic approach[Luborsky & Barrett, 2007] and unmet needs in ourformulation). It also shares an understanding thatunfulfilment (real or perceived) of wishes is visible in

a client’s distress; this parallels our understanding ofthe interplay between the triggers and unmet needs.Furthermore, one can also see that, similar to psycho-dynamic approaches (e.g., Curtis & Silberschatz, 2007),we highlight the role of a client’s original painful expe-riences in the formation of sensitivity to particular trig-gers and in the formation of a particular self-treatment(e.g., pathogenic beliefs in Curtis & Silberschatz’s andWeiss’s [1993] understanding).We can also see similarities with cognitive–behavioural

approaches in recognizing the importance of emotionalavoidance (e.g., Barlow et al., 2004; Foa et al., 2007) thatprevents the processing of upsetting experiences. Ourdescription of self-treatment and negative thoughts aboutthe self (core dysfunctional self-beliefs) are similar to thosefound in cognitive therapy (cf. Beck et al., 1979). The em-phasis that our model places on emotional processingmay also be a common element between our model andsome CBT approaches (see, for instance, Watson andBedard [2006] for discussion on the role of experiencingin both EFT and CBT and Castonguay et al. [1996] exami-nation of experiencing in CBT). Indeed, some CBTapproaches understand emotional processing as not onlypurely in terms of exposure (e.g., Foa et al., 2007) but alsoin terms of awareness and in identifying points of emotionavoidance. Furthermore, there is also a similarity betweenaspects of our approach and the importance given to self-compassion in compassion-focused CBT (Gilbert, 2009),although the model we use herein gives equal emphasisto healthy assertive anger.However, there are also many important differences

between our presentation and that of the other theoreticalapproaches. Some of these major differences are capturedin the ultimate goal of conceptualization and therapeuticstrategy. For instance, in some psychodynamic therapies,case formulation is primarily used to help the client achievesome insight into the painful feelings and their reworkingin the relationship with the therapist (e.g., see Luborsky &Barrett, 2007). Similar to behavioural approaches, we ratherput emphasis on the experience of self-generated adaptiveemotions (such as self-compassion, protective anger andadaptive grieving) rather than attributing change to newconceptual-cognitive understandings. Even so, like psycho-dynamic schools, we believe that an empathic and validat-ing relationship can play an important role in a client’sexperience of healthy emotions whether in the relationshipwith others or with the therapist.In some cognitive–behavioural therapies, the case

conceptualization is intended to provide a rationale for re-placing dysfunctional beliefs about the self with moreadaptive ones (e.g., Beck et al., 1979) or to encourage themastery of problematic symptoms or avoided situations(Barlow et al., 2004). We believe that the model presentedherein can offer a nuanced conceptualization of what sortof emotions may be linked with the problematic beliefs



and are the most painful and avoided, which needs are notbeing met and what emotional experiences are necessary into order to transform the painful feelings. This perspectivecould perhaps be incorporated into other interventionapproaches. However, the presented model also elaboratesthe observation that transformation of painful emotionalexperiences through the generation of an adaptive andhealing emotional experiences is a complex process, onethat entails several sequential steps and require a differenttherapeutic strategy depending on the step in that process.

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